Summary Report for FSPSAs Initiated During the Report Period Statewide
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs starting between: 04-01-18 and 06-30-18 Date of Report: 08-10-18 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
With the filters selected there were 28526 FSPSA's found
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
SCONLY-SCONLY *SERVICE COORDINATION ONLY 196 203 272.065878 $0.0000 $0.0000
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 4 8.266667 $0.0000 $0.0000
TCM -T1017TL TARGETED CASE MANAGEMENT 3 3 2.411111 $89.2100 $37.0000
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Subtotal (Total Children Is Unduplicated) 202 210 282.743656 $89.2100 $0.3200
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 99 119 70.069426 $3398.3700 $48.5000
AUD -92626 EVAL OF AUD REHAB STATUS 10 11 12.057860 $619.1700 $51.3500
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 2 2 3.033333 $54.3600 $17.9200
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 325 328 342.414286 $7310.5500 $21.3500
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 11 11 6.438889 $81.1900 $12.6100
AUDE -92557 COMP AUDIO THRESHOLD EVAL/SPCH RECO 34 34 15.158523 $326.6700 $21.5500
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 26 26 29.257011 $241.6600 $8.2600
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 29 29 32.257011 $816.4200 $25.3100
AUDE -92582 CONDITIONED PLAY AUDIOMETRY 2 2 3.033333 $106.0700 $34.9700
AUDE -92585 AUD EVOKED RESPONSE (COMP) 9 9 5.183334 $399.8000 $77.1300
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 22 22 18.285582 $339.2000 $18.5500
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 4 4 5.866666 $121.3200 $20.6800
AUDE -V5010 ASSESSMENT FOR HEARING AID 7 7 13.585878 $611.3700 $45.0000
AUDE -V5090 DISPENSING FEE PER HEARING AID 13 13 17.412513 $2002.4400 $115.0000
EVAL -96111 DEVELOPMENTAL EVALUATION 23 30 6.991169 $349.5800 $50.0000
EXIT -EXIT EXIT ASSESSMENT 420 439 821.949499 $41097.4700 $50.0000
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 1 1.500000 $112.5000 $75.0000
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 40 48 60.427016 $4532.0400 $75.0000
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 19 26 22.676256 $1700.7200 $75.0000
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 6.005479 $450.4100 $75.0000
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 44 65 70.718420 $5303.9000 $75.0000
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 29 35 29.205859 $1620.9200 $55.5000
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 442 442 711.610353 $53370.8300 $75.0000
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 239 239 399.984330 $29998.8800 $75.0000
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 79 79 132.536988 $9940.2500 $75.0000
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 579 580 859.985849 $47729.2500 $55.5000
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 348 379 539.516635 $40463.7500 $75.0000
NUTR -97803 NUTRITIONAL EVAL, FOLLOW-UP 4 4 12.639683 $631.9800 $50.0000
OCTF -97168 OT RE-EVAL EST PLAN CARE 52 52 15.388891 $785.6100 $51.0500
OCTH -97165 OT EVAL LOW COMPLEXITY 10 10 8.388660 $428.2400 $51.0500
OCTH -97166 OT EVAL MODERATE COMPLEXITY 56 59 41.437747 $2115.4000 $51.0500
OCTH -97167 OT EVAL HIGH COMPLEXITY 241 252 145.818912 $7444.0300 $51.0500
PSTF -97164 PT RE-EVAL EST PLAN CARE 37 39 9.635716 $491.9100 $51.0500
PSTH -97161 PT EVAL LOW COMPLEXITY 8 8 8.079137 $412.4400 $51.0500
PSTH -97162 PT EVAL MODERATE COMPLEXITY 40 42 30.202206 $1541.8300 $51.0500
PSTH -97163 PT EVAL HIGH COMPLEXITY 252 273 124.322085 $6346.6200 $51.0500
SCREEN-T1023 SCREENING 37 38 30.171843 $1508.6000 $50.0000
SPCH -92521 EVAL OF SPEECH FLUENCY 8 8 3.894444 $198.8100 $51.0500
SPCH -92522 EVAL OF SPCH SOUND PROD 22 22 16.253652 $829.7500 $51.0500
SPCH -92523 EVAL OF SPCH SOUND PROD; EVAL LANG 363 403 220.288958 $11245.7700 $51.0500
SPCH -92524 BEHAV & QUAL ANALYSIS OF VOICE AND 29 29 21.960359 $1121.0600 $51.0500
SPCH -92610 EVAL OF ORAL,PHARYNGEAL SWALLOWING 16 16 15.099684 $672.6900 $44.5500
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Subtotal (Total Children Is Unduplicated) 2650 4239 4940.743475 $288873.8100 $58.4700
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 94 105 77.809165 $389047.5000 $5000.0200
AUD -92592TS AUDIOLOGY SERVICES (Monaural) 4 4 4.155556 $207.7800 $50.0000
AUD -92593TS AUDIOLOGY SERVICES (Biaural) 26 27 17.776427 $888.8100 $50.0000
AUD -92630 AUD REHAB PRELING HEARING LOSS 1 1 0.002740 $0.1900 $70.5500
AUD -92633 AUD REHAB POSTLING HEARING LOSS 5 5 6.992065 $500.7100 $71.6100
AUDE -V5160 DISPENSING FEE BINAURAL 19 19 9.103653 $2093.8500 $230.0000
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 752 869 603.136200 $30157.0100 $50.0000
COIFP -COIFP IFSP CONSULT, PROF, BY PHONE 65 69 46.927404 $1173.1900 $25.0000
CONIF -CONIF CONSULT, ITDS FACE TO FACE 2013 2355 3134.543607 $156727.3200 $50.0000
CONIP -CONIP CONSULT, ITDS PHONE 137 145 154.200001 $3855.0000 $25.0000
CONOF -CONOF CONSULT, OT, FACE TO FACE 628 775 1024.103972 $51205.2300 $50.0000
CONOP -CONOP CONSULT, OT, PHONE 60 105 76.388886 $1909.7200 $25.0000
CONPF -CONPF CONSULT, PT, FACE TO FACE 576 660 933.948833 $46697.5300 $50.0000
CONPP -CONPP CONSULT, PT, PHONE 28 43 39.255557 $981.3900 $25.0000
CONSF -CONSF CONSULT, SLP, FACE TO FACE 1498 1623 1982.316424 $99115.8300 $50.0000
CONSP -CONSP CONSULT, SLP, PHONE 119 122 130.538890 $3263.4800 $25.0000
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 13 15 48.188889 $3533.2200 $73.3200
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 225 304 1646.772194 $41169.2800 $25.0000
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 6 6 25.728571 $1286.4300 $50.0000
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 5706 6258 40146.401722 $2007318.9900 $50.0000
INTR -T1013 INTERPRETER 188 217 1008.702774 $50435.1200 $50.0000
NESF -99600 NATURAL ENVIRONMENT SUPPORT FEE 3310 4655 23288.992988 $232889.7700 $10.0000
OCCT -97530 OT SESSION BY LICENSED OT 811 897 4442.019458 $317337.9000 $71.4400
OCCT -97530HM OT SESSION BY OT ASST 149 165 909.985714 $52051.1600 $57.2000
PHY -97110 PT SESSION BY LICENSED PT 839 936 4810.838892 $343686.2400 $71.4400
PHY -97110HM PT SESSION BY PT ASST 64 66 361.750000 $20677.6200 $57.1600
RSPT -RSPT RESPITE 1 1 9.571429 $0.0000 $0.0000
SENS -HA_INS SENSORY AID INSURANCE PER EAR 3 3 0.338737 $22.0200 $65.0100
SENS -V5050 IN EAR MONAURAL HEARING AID 5 5 3.512329 $800.8000 $228.0000
SENS -V5060 BEHIND EAR HEARING AID 3 3 3.273973 $746.4700 $228.0000
SENS -V5140 BEHIND EAR BINAURAL HEARING AID 4 4 9.758100 $4449.7400 $456.0000
SENS -V5264 EARMOLD 27 28 32.905000 $592.2900 $18.0000
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 1184 1314 7202.871080 $514573.2800 $71.4400
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 9 10 37.571430 $2149.0900 $57.2000
SPL -92508 GROUP SPL SESSION PER CHILD 29 30 294.169841 $4083.0800 $13.8800
TRAV -TRAVS Travel by mile 1222 2233 167493.911981 $74534.7900 $0.4500
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Subtotal (Total Children Is Unduplicated) 7620 24077 260018.464482 $4460161.8200 $17.1500
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Total 28526 265241.951613 $4749124.8500 $17.9000
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Number of Children (Unduplicated) With at Least One Authorization 8101